Hidden Malnutrition Worsens Health of Elderly

By JAMES BENNET

Published: October 10, 1992

Dr. Howard Fillit has come up with a low-cost way to fend off, and even reverse, what most people view simply as the inevitable ravages of age: He feeds people.

Up to 40 percent of the scores of very sick, elderly patients Dr. Fillit sees at Mount Sinai Medical Center are malnourished, he said, even though they -- and their families and nursing aides, when they are lucky enough to have either -- usually do not realize it. In many cases, he said, their bad diet has caused, or at least severely worsened, their pneumonia, their heart trouble or even their dementia.

"If they were objective, they would see themselves as skeletons," said Dr. Fillit, who runs Sinai's Geriatric Evaluation and Treatment Unit. "But they just see themselves as old."

The extent of malnutrition among the elderly in general is a murky battleground for their advocates, public health officials and assorted experts. While some nutritionists estimate that 50 percent of all elderly Americans open themselves up to a host of diseases by not eating enough of the foods they need, very little is known about the problem.

"I'm a little embarrassed to tell you that I can't deliver good information on this," said Dr. Irwin H. Rosenberg, director of the United States Department of Agriculture's Human Nutrition Research Center on Aging at Tufts University. A study of studies on elderly nutrition by the General Accounting Office, released July 30, was titled: "Nutrition Information Is Limited and Guidelines are Lacking."

Doctors and nurses who are not trained to spot malnutrition in older people often fail to detect it. "We can't even define malnutrition well for elderly people," said Dr. James Cooper, a geriatrician at the National Institute on Aging, part of the National Institutes of Health. "We think that much more malnutrition occurs that is not labeled or obvious."

But there are studies -- like one conducted by Dr. Fillit, who plans to publish his results in the next few months -- that suggest that malnutrition runs high among elderly who require hospitalization. For example, hospital studies have shown that between 30 and 61 percent do not receive the protein they need.

And there are areas of general agreement. Because they lose their teeth or their sense of taste as they age, or because they cannot climb three flights of stairs to their apartments with a cane in one hand and a shopping bag in the other, the elderly, particularly the poor, are more likely than younger people to eat badly; and eating badly makes the healthy elderly sick, and the sick elderly die.

Hence the living skeletons that keep turning up on Dr. Fillit's doorstep. "Every day they come in, and the primary diagnosis from a geriatrician's point of view is malnutrition and social impairment," he said. "What good is it going to do to give them the right antibiotic for pneumonia and send them back home?" 'It's All Reversible'

People often have weakened their immune systems, already slipping as a natural consequence of age, by not eating properly. "These people are dying from infections," he said. "That's how people in Somalia are dying."

Sometimes the old people he sees are confused, displaying what look like the symptoms of Alzheimer's Disease. But on closer examination, he has discovered that they were simply lacking adequate amounts of B12, a vitamin commonly found in meat, fish and milk. "It's all reversible," he said.

Congress passed a bill this summer to create a three-year, $9 million program to assess malnutrition among the elderly and to determine if the government could save money by regularly testing older people for malnutrition to head off more costly hospital stays later. But the bill was attached to legislation to reauthorize funding for the National Institutes of Health, which President Bush vetoed for reasons unrelated to the program.

There are several clinical measurements for malnutrition, including checking a person's body weight or muscle mass against standard charts or testing the level of certain types of protein in the blood. In addition, nutritionists examine people's diets to see if they meet the Federal Government's recommended daily allowances for nutrients. But little is known about the real dietary needs of the elderly. The Federal Government simply uses the same allowances for all people over the age of 51. Food, but No Appetite

Dr. Michael Freedman, director of geriatrics at New York University-Bellevue Hospital Center, also puts the proportion of malnourished elderly patients he sees at 30 to 40 percent. "We are seeing more people with malnutrition," he said.

"The question is why," he said. "It's not because there isn't enough food in the city of New York."

Indeed, experts on nutrition for the elderly increasingly view the traditional solutions to the problems of hunger and malnutrition -- social policy fixes like Meals on Wheels -- as inadequate.

As the elderly population ages, people develop chronic illnesses that kill their appetites or make it difficult for them to cook or eat. In addition, the drugs they take can suppress hunger, and deterioration of their senses can make them lose interest in food. In other words, even if one brings elderly people food, they will not necessarily eat.